Preoperative Evaluation for Free Functional Muscle Transfer in Upper Extremity Amyoplasia: A Multicenter Report of 3 Cases.

CASE: A multicenter series of 3 patients with amyoplasia of the upper extremity were indicated for gracilis free functional muscle transfer (FFMT) to restore elbow flexion and found to have an absent gracilis. A final case is discussed detailing standardized evaluation with ultrasound to confirm gracilis before surgical intervention. CONCLUSION: In amyoplasia, the gracilis muscle may be absent or have fatty infiltration, making this donor muscle inadequate. Preoperative ultrasound to determine the presence of the gracilis is noninvasive and recommended in patients with amyoplasia of the upper extremity being considered for FFMT.

Long-term donor site outcome after second toe transfer for congenital hand differences.

This study evaluates the long-term donor site outcomes after second toe transfers for congenital hand differences performed during childhood. In total, 25 toe transfers in 18 patients were followed up for a mean period of 17.4 years. We examined the patients clinically, radiologically and with a gait analysis system. Patient-reported outcome measures were collected. The patients were asymptomatic and there were no problematic clinical or radiological findings. Patients expressed high levels of satisfaction. The results were consistent, regardless of the resection level in the toe transfer or whether the operation was unilateral or bilateral. No postoperative complications or late reoperations on the foot were observed.Level of evidence IV.

Distal Radio-Ulnar Joint Reconstruction after failed Darrach operation using free autogenous second toe Metatarso-phalangeal joint transfer. Development of the technique and a long-term (over 25 year) follow-up.

During the development of microvascular surgery in 1980-95 many new methods to overcome different traumatic disorders were studied. Previously unsolved problems could be treated using free tissue transfer. Typical problems in wrist surgery were the painful complications from ulna head resection. No sound or acceptable artificial protheses for ulna head were available. Author did study the possibilities of reversal of resected ulna head using an autogenous microvascular joint transfer. First it was done using cadaver models and evaluating the possibilities of a toe MTP-II joint in replacing the distal radio-ulnar joint. Then same principle was used in three clinical cases. All patients had suffered a poor result after ulna head resection or Darrach procedure. First two cases had complications but third case from year 1994 resulted in a good outcome. This paper introduces the development of a surgical technique for the replacement of the resected ulna head. Also, it will describe the excellent long-term result achieved in the last case with 26-year follow-up. Although today many sophisticated prosthetic replacement techniques have become developed for this purpose, this kind of autogenous reconstruction might have a place in treating similar problems in young posttraumatic patients. Also it demonstrates the potential benefit of microsurgery in a difficult wrist problem.

The Modified Vilkki Procedure: Vascularized Metatarsophalangeal Joint Transfer to Reconstruct a Full-Length Radius in Type III Radial Hypoplasia.

Radial longitudinal deficiency is a spectrum of deformity ranging from thumb hypoplasia to a shortened or absent radius. Traditional treatments are hindered by recurrent deformity and disruption of future forearm growth. These deficiencies can be addressed by a Vilkki procedure in which a free second toe metatarsophalangeal joint is used to restore a radial column and provide viable physes for continued forearm growth. A classic Vilkki procedure positions the proximal toe metacarpal on the native ulna to create a Y-shaped one-bone forearm. We report a case of a modified Vilkki procedure in which a 2-bone forearm is created using the proximal toe metacarpal to reconstruct the entire radius. In patients with type III radial longitudinal deficiency with suitable residual radius length, the modified Vilkki procedure can allow reconstruction of a 2-bone forearm. This affords the patient correction of the pathoanatomy and the potential for balanced growth and pronosupination.

Long-term outcomes after pollicization: a mean 11-year follow-up study.

This study evaluates the long-term results of pollicization for a congenitally absent or severely hypoplastic thumb. Twenty-nine patients with 34 pollicizations were divided to two groups: those with simple thumb hypoplasia (22 pollicizations) and those with radial longitudinal dysplasia (12 pollicizations). The patients were followed from 1.3 to 32 years, with a mean follow-up time of 11 years. The patients were examined clinically and radiologically, and they completed a questionnaire concerning satisfaction with appearance, function, and social interaction. The Percival score was also calculated. In both groups, grip and pinch strengths of the operated hands were inferior to the normative age-related values. Radiologically, flattening of the original metacarpal head was found in 20 out of the 34 operated hands. We found better patient satisfaction in the simple hypoplasia group than in the radial longitudinal dysplasia group. The functional outcomes and patients' satisfaction did not correlate with the age of patients at operation. Level of evidence: IV.

Vascularized second metatarsophalangeal joint transfer for radial deficiency - an update.

Vascularized second metatarsophalangeal joint transfer offers a possibility to reconstruct the radial support which is lacking in radial dysplasia. Our experience from 1987 to 2017 with 34 congenital radial club hand reconstructions have allowed a possibility for long-term evaluation of the method. Compared with conventional methods, second metatarsophalangeal joint transfer results in better wrist mobility and does not restrict typical ulnar growth. The balance of the wrist remains good until age 11. Thereafter, the growth of the vascularized bone graft transfer matches only partially the distal ulnar growth in adolescence, resulting in mild recurrence of radial deviation. A new option to create a two-bone forearm in selected Bayne-Klug Type III radial dysplasia cases will allow a relatively good pro-supination ability. Potentially, a proximal fibular epiphyseal transfer could be a future solution. Currently, a safe harvest of the proximal fibula at childhood remains controversial.

Changing paradigms in the treatment of radial club hand: microvascular joint transfer for correction of radial deviation and preservation of long-term growth.

Radial longitudinal deficiency, also known as radial club hand, is a congenital deformity of the upper extremity which can present with a spectrum of upper limb deficiencies. The typical hand and forearm deformity in such cases consists of significant forearm shortening, radial deviation of the wrist and hypoplasia or absence of a thumb. Treatment goals focus on the creation of stable centralized and functionally hand, maintenance of a mobile and stable wrist and preservation of longitudinal forearm growth. Historically centralization procedures have been the most common treatment method for this condition; unfortunately centralization procedures are associated with a high recurrence rate and have the potential for injury to the distal ulnar physis resulting in a further decrease in forearm growth. Here we advocate for the use of a vascularized second metatarsophalangeal joint transfer for stabilization of the carpus and prevention of recurrent radial deformity and subluxation of the wrist. This technique was originally described by the senior author in 1992 and he has subsequently been performed in 24 cases with an average of 11-year follow-up. In this paper we present an overview of the technique and review the expected outcomes for this method of treatment of radial longitudinal deficiency.

Vascularized metatarsophalangeal joint transfer for radial hypoplasia.

The relatively new concept and technique of microvascular joint transplantation for the correction of the congenitally deformed wrist is presented with a series of 24 operated radial club hands. The results from the 19 upper extremities with a mean follow-up of 11 years show that the new technique will not diminish the longitudinal growth of the ulna. The ulna length in the series is now 15.4 cm in mean and will develop further and presumably better than that reported in the previous long-term studies after centralization. The superiority in wrist active mobility compared with those of some previous long-term studies is reported with total active motion of 83 degrees in mean. The radial deviation deformity has become increased by 12 degrees in mean in the long-term follow-up compared with the results reported previously by the same author in the series of the first nine patients in 1998. The balance in the growth between the supporting metatarsal joint and the distal ulna has remained satisfactory, and the resting radial deviation angle is 28 degrees in mean (range, 0 to 45 degrees) in the cases with successful joint transfer. A subluxation tendency in six of the transplanted joints is a new finding, and its prevention needs careful attention during the reconstruction. With respect to timing, the joint alignment and transplantation procedure is best performed between the ages of 2.5 and 4 years according to the current experience of the author. A pollicization is usually added after the wrist alignment procedure. This technique will give the child a period of ~10 years without any new need for surgical treatment, and usually no splinting is needed during that period. However, an additional corrective osteotomy may be needed at early puberty depending on the growth properties of the joint graft and original ulna and because of ulnar bowing. The reported technique with preoperative and postoperative measures takes a period of about one-half year, and the whole procedure is considered quite demanding as far as an adequate preoperative soft tissue distraction and the microvascular joint transplantation are concerned. It is recommended that the treatment be performed in dedicated microsurgical centers with adequate pediatric tissue transfer experience.

A new concept and technique for custom-made microvascular lunate bone reconstruction.

Kienböck's disease is always a challenge, especially when the lunate is already fragmented. Despite the numerous methods to treat this wrist problem, results have often not been satisfactory. Swanson's silastic lunate prosthesis has not been a helpful solution for most patients over the long-term, and problems with artificial material have also become apparent. A proposal to create an autogenous microvascular total lunate bone reconstruction is presented. The second metatarsophalangeal joint was used in a new fashion to create a biologic substitute for the lunate bone. This is called a "neolunate." The lunate bones and neolunates created from the second metatarsophalangeal joints of fresh cadavers were compared. The possibilities of microvascular access to create a neolunate and its use in wrist reconstruction were studied in ten cadaveric wrists. The lunates and neolunates were compared. After a neolunate reconstruction, the specimen was inserted into the original cadaveric wrist and the ligamentous structures were repaired. The necessary architecture for ligament stability to prevent subluxation and DISI or VISI deformity was established. Radiological measurements confirmed the neolunate as a suitable model. The result was close to normal wrist configuration. So far, only one clinical trial using the proposed technique has been done. The proposed microsurgical neolunate transfer needs further clinical testing to prove its potential value. A disadvantage is that the method is technically demanding.

Present technique and long-term results of toe-to-antebrachial stump transplantation.

Complete hand amputation has been considered conventionally as an indication for the use of mechanical prosthetic devices in order to regain some hand like function. A microsurgical option to create a new pinching ability after wrist amputation has been used in a series of 13 patients. The actual operation technique is presented in detail. It was designed by the senior author in 1981 and applied into clinical use in 1983. In order to evaluate the functional results and patient satisfaction in long-term, a questionnaire was sent to 12 patients and 11 patients were interviewed, examined clinically and studied with a hand function scoring test according Sollerman. The operated series consist of 12 adults with posttraumatic distal antebrachial or wrist amputations and 1 adolescent boy with a congenital wrist level amputation. There were 3 females and 10 males in the series. The satisfaction to achieved result was generally good. The ADL section of Tamai score and the one we used correlated well with each other and patient satisfaction. Sollerman hand function test gave worse results in two blind patients and same occurred in two short antebrachial stump patients. However the satisfaction was much better in Tamai score among blind patients, with wrist amputation level amputations. In our opinion this single toe transfer method gives an acceptable pinch reconstruction for hand amputation patients. We measured pinch strength and total active motion. They averaged about half of the normal values. The reconstruction is suitable to the patients, who are not willing to donate multiple toes or who are aware and concerned about the risks of human hand transplantation, which necessarily will need a life-long immunosuppressive medication to prevent from rejection.